Integrated management of concurrent traumatic penetrating brain injury and electrical injury: illustrative case

Abstract

BACKGROUND

Transorbital penetrating brain injury (PBI) accompanied by electrical injury is an extremely rare presentation. This type of traumatic injury has a unique set of diagnostic and therapeutic challenges due to the potential multiple organ system involvement and severe neurological complications.

OBSERVATIONS

A 50-year-old male experienced a high-impact injury from a welding spike that penetrated the orbit just above the eyeball with a concurrent electrical injury; the electricity exited through the great toe. Initial assessments revealed extensive subarachnoid pneumocephalus and a linear hemorrhage extending from the left medial orbital wall through the ethmoid air cells to the right thalamic nucleus. Remarkably, the eye itself was not injured given the superior trajectory of the spike within the orbit.

LESSONS

PBIs and electrical injuries usually cause serious sequelae, but the welding spike and electrical current managed to avoid major neuroanatomical structures and visceral organs, allowing the patient to recover with minimal deficits.

https://thejns.org/doi/10.3171/CASE24418

Transorbital penetrating brain injuries (PBIs) account for only 0.4% of all head injuries but up to 24% of PBIs in adults.^{1, 2} Although rare, the few cases described in the literature have varied outcomes, including significant morbidity.^{2, 3} Similarly, traumatic electrical injuries often result in long-standing organ dysfunction or fatality.⁴ However, we present the unique case of a transorbital PBI with a welding spike and coinciding electrical injury in a patient with a favorable outcome. We discuss evaluation, management, and the role of prompt interdisciplinary care to achieve positive patient outcomes.

Illustrative Case

A 50-year-old male experienced a high-impact injury from a welding spike that penetrated the orbit just above the eyeball with concurrent electrical injury. Immediate intervention at the scene involved removal of the welding probe by his colleague prior to his arriving to the emergency department. On initial assessment, the patient exhibited a left eyebrow laceration (1–2 mm) with surrounding periorbital ecchymosis. His extraocular muscles were intact, and his pupils were equally reactive to light (2+). He was hypertensive (162/93 mm Hg), but his heart rate, respiratory rate, and temperature were within normal limits. On examination, he was alert and oriented but exhibited mild confusion. Cranial nerves II–XII were grossly intact; however, he had an effort-dependent House-Brackmann grade II facial weakness visible when smiling. Otherwise, he exhibited 5/5 upper- and lower-extremity motor strength.

Imaging consisted of computed tomography (CT) without contrast, which revealed extensive pneumocephalus and evidence of linear hemorrhage along the penetrating injury line from the left medial orbit wall through the ethmoid air cells, cribriform plate, and gyrus rectus toward the right thalamic nucleus (Fig. 1). Maxillofacial CT without contrast additionally demonstrated a small displaced bone fragment measuring 2 mm in the region of the gyrus rectus, without frontal sinus involvement (Fig. 2). CT angiography (CTA) was also performed to rule out vascular injury and only demonstrated some intracranial hemorrhage, as described above. Additional imaging included abdomen and pelvis CT with contrast, chest CT with contrast, cervical CT without contrast, chest radiograph, and pelvic radiograph, but all were unremarkable. The patient was admitted to the intensive care unit (ICU) for 48 hours of observation, with hourly neurological checks and monitoring for cerebrospinal fluid leaks. Oxygen was initially administered via a nonrebreather mask, which contributed to the early resolution of the extensive pneumocephalus observed on imaging (Fig. 3). Head CT demonstrated focal edema surrounding the hemorrhage in the thalamus 72 hours postinjury (Fig. 4). The patient underwent aggressive hydration for transient rhabdomyolysis and observation for the development of signs of elevated intracranial pressure (ICP). However, there was no indication for the placement of an ICP monitor because of the patient’s Glasgow Coma Scale score of 15. He was also started on a 7-day course of prophylactic vancomycin and ceftriaxone, which have central nervous system coverage.

FIG. 1.

Axial head CT scans without contrast demonstrating extensive pneumocephalus (A) with evidence of a PBI with a linear area of hemorrhage extending from the left medial orbital wall through the ethmoid air cells, through the cribriform plate and gyrus rectus, and ending in the right thalamic nucleus (B and C).

FIG. 2.

Axial maxillofacial CT scan without contrast (A) with coronal (B) and sagittal (C) reformats obtained at initial evaluation in the emergency department, demonstrating a fracture involving the left medial orbital wall and ethmoid air cells and extending through the cribriform plate on the left. There is a small displaced bone fragment within the region of the gyrus rectus that measures approximately 1.4 mm.

FIG. 3.

Axial head CT scans without contrast obtained 24 hours following injury, demonstrating significant improvement and almost complete resolution of the patient’s extensive pneumocephalus with stable hemorrhage on interval imaging.

FIG. 4.

Axial head CT scans without contrast obtained 72 hours following injury, demonstrating increased focal edema surrounding the localized hemorrhage in the right thalamus.

On hospital day (HD) 2, he was downgraded from the ICU to the general inpatient floor. The patient’s neurological examination remained intact until he began to develop a fever of 100.6°F on HD 5. On examination, he had decreased strength (4/5) in his upper left extremity and full strength with dysmetria in his lower left extremity. The infectious disease (ID) team was consulted, and infectious causes of the fever were ruled out through extensive evaluations, including blood cultures and imaging studies. The ID team advised against a lumbar puncture due to the patient’s lack of meningeal symptoms. Following these recommendations, the patient’s antibiotics were discontinued after a 5-day completion, and the fevers were treated as neurogenic due to the patient’s injury. The patient’s final fever was 100.6°F on HD 7, and his physical examination returned to baseline with full strength thereafter. The cause of the weakness was attributed to the fevers and not a structural injury due to the delayed presentation and spontaneous resolution. There was also a low suspicion for Todd’s paralysis, as the patient was on prophylactic antiepileptic therapy and he was with a 1:1 sitter throughout his stay, who noted no visible signs of seizures. However, management for future patients could include electroencephalography testing to definitively rule out seizure activity.

The 2- to 3-mm eyelid injury only required minimal suturing and healed without complications, with no further follow-up necessary, as determined by the ophthalmology team. Since the patient did not present with an open fracture, wound washout and debridement were not indicated, and the imaging results further supported this. He was then transferred to inpatient rehabilitation on HD 9, where his fevers continued to be monitored. He remained afebrile during his stay and was discharged home on HD 14. Three months after the injury, the patient followed up in the clinic, where imaging was performed to assess for any delayed complications. The CT scans demonstrated full resolution of the hemorrhage (Fig. 5), and the patient made a full recovery without cognitive deficits.

FIG. 5.

Axial head CT scan without contrast obtained 3 months following injury, demonstrating resolution of the hemorrhage from the penetrating injury.

Informed Consent

The necessary informed consent was obtained in this study.

Discussion

Observations

The case presented is a unique combination of a transorbital penetrating injury with concurrent electrical injury. A literature review was conducted, and, to our knowledge, there are no existing cases with both elements. However, there is literature on the individual elements of our case. Transorbital penetrating injuries are a rare type of traumatic brain injury, more commonly reported in the pediatric population. The orbital roof and superior orbital fissure have been highlighted as the two most common routes of intracranial penetration.⁵ According to the zone-entry model of Turbin and colleagues, the welding spike in this case entered the orbit via the superomedial region of zone 1, which is commonly associated with frontal lobe abscesses, contusion, or displaced bony fragments, as seen in our patient.⁶ Various penetrating objects have also been described in the literature,^7–10 and outcomes depend heavily on the trajectory of the foreign body and the neuroanatomical structures traversed.¹¹ Outcomes are further impacted by complications such as infection causing meningitis or retained foreign bodies leading to abscesses.^{5, 12, 13} Although rare, neurovascular injuries, including hematomas, aneurysms, or vasospasm, can also occur. According to Bodanapally et al., this patient was at an increased risk of arterial injury because the entry wound was located over the frontobasal region.¹⁴ Hence, CTA was performed to rule out vascular injury, and CT scanning was conducted to rule out the presence of retained foreign bodies and abscesses. Follow-up CTA was also ordered on HD 6, displaying no new areas of hemorrhage or pseudoaneurysm and near-complete resolution of the patient’s pneumocephalus. Given the patient’s occupation as a welder and the risk of metallic particles in his eyes following the PBI, the radiology team did not clear him for magnetic resonance imaging (MRI). Metallic intraocular foreign bodies are an absolute contraindication for MRI,¹⁵ but orbit radiographs can be obtained and reviewed by the radiology team to determine if patients are eligible for MRI following welding injuries.

The patient presented with the secondary element of simultaneous electrical injury with intracranial penetration. True electrical injuries involve the patient becoming part of an electrical circuit, with entrance and exit sites present.⁴ The current entered this patient at the transorbital penetration site and exited through his great toe. Although electrical injury is common, there is limited literature on its neurological effects. Yiannopoulou et al. conducted a review on the neurological sequelae of electrical injury and found that peripheral neuropathies, neurourological symptoms, and central nervous system complications such as cerebral edema and hydrocephalus have been reported.¹⁶ However, this patient’s presentation lacked the common neurological sequelae described above. Although removal of foreign bodies is not advised, the removal of the welding spike in this case might have protected the patient from neurological damage, as his brain was exposed to the electrical current for a shorter period. Foreign bodies are usually left in place until imaging is performed because foreign bodies can prevent severe bleeding, and removal can cause further damage to surrounding structures,¹⁷ but, fortunately, this patient experienced minimal bleeding and no additional damage. There was no indication for surgical intervention due to the absence of the foreign body upon arrival to the hospital, which was further supported by the lack of metallic fragments on imaging. Although the patient’s maxillofacial CT displayed a 2-mm displaced bone fragment, the patient’s overall stable presentation did not warrant operating and increasing the risk of morbidity and further complications.

The case described is a unique hybrid presentation of both transorbital penetrating injury and electrical injury. To our knowledge, this is the first case reported of this nature. The trajectory of the welding spike failed to damage major cerebral structures, and the path of the electric current also avoided visceral damage, allowing the patient a positive outcome.

Lessons

The case underlines the critical role of prompt, detailed imaging in directing the clinical management of PBIs and monitoring for potential complications such as hemorrhages and pneumocephalus. Our case is a reminder that determining whether surgical intervention is appropriate or not is a difficult judgment that neurosurgeons face. It is important to consider whether the possible benefits outweigh the surgical risks and whether the patient truly needs surgery to recover. The comprehensive approach involving neurosurgery, ID consultation, and physical rehabilitation was crucial for addressing the spectrum of trauma complications effectively. Early and comprehensive interdisciplinary care, including prompt medical interventions and vigilant management of potential complications, is pivotal in achieving positive outcomes in complex cases of PBI with electrical injury.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Hutchins. Acquisition of data: Hutchins. Analysis and interpretation of data: Vega, Hutchins. Drafting the article: Vega, Raelly-Muze. Critically revising the article: all authors. Reviewed submitted version of manuscript: Vega, Hutchins. Approved the final version of the manuscript on behalf of all authors: Vega. Administrative/technical/material support: Raelly-Muze.

Correspondence

Rafael A. Vega: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. rvega@bidmc.harvard.edu.